The broad, long-term objective of this project is to improve the effectiveness and efficiency of care for patients with chronic conditions through the use of HIT (Research Area 2), specifically the incorporation of an interactive patient portal withi advanced patient-centered medical home practices. This project proposes an innovative use of Health Information Technology (HIT) functionality for patients, providers and care managers to monitor health care plans; and to evaluate the impact on patient self- management and cost reduction. The project will be implemented in [five] primary care practices that have Electronic Medical Records connected to a Health Information Exchange (HIE), and an advanced patient- centered medical home model of care. All [five] practices 1) Have electronic medical records (Centricity(R), GE Healthcare), Care Catalyst web-based patient portal (Kryptiq Corp) and Instant Medical History software (Primetime Medical Software) that creates the interface between the EMR and the patient portal, thus allowing patients to enter information that can be included in their EMR; and 2) Are current participants in a Beacon Community project, funded by the Office of the National Coordinator. This project will explain the challenges and solutions for the implementation of a web-based portal for chronic condition patients with diabetes mellitus, congestive heart failure and chronic obstructive pulmonary disease within a care management model. The Specific Aims of Phase I will develop the interfaces between the EMR and the patient portal with the disease-specific plan of care forms, and patient referred information. The Specific Aims of Phase II will evaluate the implementation and effectiveness of the inclusion of the web-based patient portal into the plan of care process by assessing the perception of the users, including system adoption, and satisfaction by patients, care managers, and providers. [Perceptions of non-users of the patient portal will also be assessed to identify barriers to adoption.] Phase II will incorporate the data collection process to assess health care utilization related to tertiary and urgent care uses, and to follow up on the self-efficacy, functional status, clinical outcomes, and plan of care adherence rate among the high risk/high cost chronic disease patients using the web-based patient portal. Health Information Technology (HIT) has the potential to significantly improve the lives of chronic disease patients. The proposed evaluation of innovative, comprehensive use of HIT has relevance for advancing our mission, which is: Eastern Maine Medical Center provides exceptional primary and specialty healthcare with a passionate pursuit of excellence in patient safety, clinical quality, ad service. Our mission is to care for patients, families, communities, and one another. PUBLIC HEALTH RELEVANCE: Health information technology has the potential, especially in medically underserved areas, to significantly improve the lives of chronic condition patients, specifically those who represent the highest health care cost. In the eastern Maine region, based on the most recent statewide community health needs assessment (CHNA, 2010), those diseases include cardiovascular disease, diabetes mellitus, and chronic pulmonary disease. Efforts to reduce the burden towards the special care for the most needed patients, as well as interventions that promote self-management and prevention, will improve care for patients while reducing cost. The current project will improve the care coordination between health care providers, patients, and care managers by implementing a disease-specific, patient preferred/approved interactive patient web-based portal within an advanced patient-centered medical home environment. The efforts of this project are an extension of the current Bangor Beacon Community project, sponsored by the Office of the National Coordinator. The efforts are also relevant to the achievement of Stage 2 Meaningful Use of EHRs (HITPC, 2011). The proposed project directly addresses the recent recommendations (June 2011) by the Health Information Technology Policy Committee (HITPC) for Stage 2 Meaningful Use of Electronic Health Records (EHR). Specifically, HITPC suggested that EHR be used for patient education, and that patients have engaged in secure health messaging (HITPC, 2011). The Patient Portal project will include these components (patient education and secure messaging).